<html>
<body>

<form action="process.php" method="post">
    <h1>Customer Feedback</h1>
<p>Your Name: <input type="text" name="name" /><br />
E-mail: <input type="text" name="email" /></p>

<p>Your Feedback:<br />
<textarea name="feedback" rows="10" cols="40"></textarea></p>

<p><input type="submit" value="Send Feedback"></p>
</form>

</body>
</html>